training program for health care providers regarding toxic chemicals and children

8/9/2019 Training Program for Health Care Providers regarding toxic chemicals and children

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Pediatric Environmental Health Toolkit 2006

Greater Boston and San Francisco Bay Area Physicians for Social

Responsibility, UCSF Pediatric Environmental Health Specialty Unit

The Pediatric Environmental

Health Toolkit

Training Program for

Health Care Providers

2006/2007


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What We Will Cover

Background on pediatricians current practicesrelated to environmental health

The unique vulnerabilities of children

The development of the Pediatric Toolkit

Case studies on environmental exposures

How to use the Toolkit to address these issues


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Parental Concern vs. Pediatrician Advice

0

10

20

30

40

50

60

70

80

earinfections

immuniza

tion

telev

ision

caraccidents

eatingr

ight

env.t

oxins

pediatrician advisesoften

parents worry "a lot"

Stickler GB, Simmons PS., Clin Pediatr 1995


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The Environmental History in Pediatric

Practice: A Study of Pediatricians

Attitudes, Beliefs, and Practices

Fewer than 20% report training in environmental history

taking.

Strongly believe in importance of environmentalexposures to childrens health. (53.5% had patient

seriously affected)

Lack confidence in environmental history-taking, and in

discussing environmental exposures with patients.

Preferred resources: AAP patient education materials, newsletters

Kilpatrick N et al., EHP 2002


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The Chemical Environment

> 82,000 synthetic chemicals on EPAinventory of chemicals manufacturedin U.S. today

Most first synthesizedin the past 50 years

~ 700 new chemicals introducedeach year

Few chemicals tested for basictoxicity

GAO-05-458. 2005


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Chemicals Covered in Case Examples

Metals including Arsenic, Mercury and

Lead

Pesticides

Persistent Organic Pollutants (POPs)

(Example PCBs)

Second Hand Smoke (SHS)


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Unique Susceptibilities of Children

Exploratory behavior Crawling

Hand to mouth activity

Restricted diet

Teens work, hobbies,high risk behaviors

Still growing and developingAbsorption, metabolism, & elimination different

Blood-brain barrier still forming in young infants

Children differ physiologically:


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Mean WaterIntake

0

20

40

60

80

100120

140

160

180

200

gm/kg/d


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Toolkit Provider Materials


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Greater Boston and San Francisco Bay Area Physicians for SocialResponsibility, UCSF Pediatric Environmental Health Specialty Unit

Toolkit Patient Materials


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Case 1

Transient Hypertonia in an Infant

7lbs. 14 oz. term female, jaundice peak bili 12.6

Nl. PE at 12 weeks except lower extremity

hypertonicity

Pediatric consult at 16 weeks - upper and lowerextremity hypertonicity, ankle clonus with Dx of

cerebral palsy

Physical therapy begun

No environmental hx was taken

Wagner SL, Orwick DL., Pediatrics 1994


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Anticipatory uidance Card


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Urban Exposure to Pesticides

During Pregnancy Ubiquitous

NYC women wore backpack

air samplers for 48 hrs during

3rd trimester

266/314 report pest measures

at home (90% for cockroach)

ALL testing positive for

exposure to at least 4

pesticides

Cord blood levels = maternal

Chlorpyrifos associated with

decrease BW and length

Whyatt et al. Envir. Health Persp. 2002


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Indoor Residues

After Outdoor Pesticide Application

Pre-Application - 1.94 mcg/d

Post-Application 8.87 mcg/d

TwoWeeks After Application

2,4-D pesticide tracked in by

family dog and home owner

(applicator)

NishiokaMG et al. EHP 2001


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23 children monitored for metabolites before/after organic diet

Levels of urinary metabolites reduced to non-detectable for

chlorpyrifos and malathion

Again elevated on re-introduction of conventional diet

Organic Diet Reduces Exposure to Common

Agricultural Pesticides

Lu C, Toepel K, Irish R, Fenske RA, Barr DB,Bravo R, EHP. 2006


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Pesticide Report Card

EnvironmentalWorking Groupwww.ewg.org

Advice for Buying Organic


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Case 3 -

Family with Unexplained Symptoms

Family (all 8 members/2 children) develops

recurring neurologic and medical illness over

four years, worse in winter

Fatigue, rashes, seasonal alopecia

Recurrent sever respiratory infections

Debilitating headaches, malaise

Severe recurrent nosebleeds

Both children have grand mal

seizures andhyperesthesia

Fish and houseplants have died

Peters HA, CroftWA,Woolson EA, Darcey BA,OlsonMA., JAMA 1984


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Environmental History

Activities school, daycare, after school, sports,

grandparents, church, etc.

Community industry, agriculture, dump site, waterpollution, water source

Household dwelling, age, condition, heatingsources, pesticides use, SHS

Hobbies arts, crafts, fishing

Occupation known exposures, fumes, dusts,vapors, Material Safety Data Sheets

Oral behaviors pica/mouthing


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Case 3 continued

Unexplained Symptoms

Family used recycled old

wood in their stove- Chromated Copper Arsenate (CCA) treated wood

- Stove ashes with > 1,000 ppm arseniccontaminated living area

CCA commonly used wood preservative (decks,playground equipment etc.) No longer produced forresidential use.

Arsenic anti-metabolite, interferes with ATP cycle.Known human carcinogen

Kwon E. et al EHP 2004


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Advice for Patients & Providers

Topic Health Effects Summary Sources and Prevention Strategies

Routes of Exposure

Arsenic


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Case 4 -

Patient Concerned About Fish Consumption

3 y/o male with a diagnosis of

developmental/behavioral disorder at age 3

Otherwise healthy except for eczema

Normal birth Hx Exclusively breastfed for 3 months, then

transitioned to formula

Mother ate 1- 2 tuna steaks per week during 3rd

trimester and while breastfeeding Relationship to development, testing, treatment?


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Mercury: Health Effects Prenatal Exposure

Higher Dose

Mental retardation, seizures, disturbances of

vision, hearing, motor control

Lower Dose

Impairments in attention, memory, and language

Delayed conduction on BAER


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Tuna Mercury Concentrations*

Mean - 0.38 ug/g Maximum - 1.3 ug/g

Patient weight ~ 70 kg

Serving size (tuna steak) ~ 8 ozs (227 grams)

Dose Calculation (average)

0.38 ug/g x 227g x 1.5 servings / 70 kg wt. x 7 days =

0.26 ug/kg-day (high-end 0.9 ug/kg-day)

Both exceed EPA reference dose 0.1 ug/kg-day

*FDA data from 2004

Mercury Dose Calculation for

Concerned Patient


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CDC data show approximately 5.7-8% of US

women of childbearing age exceed EPA defined

safe exposure limit overnment agencies provide guidance on

mercury in fish

States provide guidance on freshwater fish

consumption guidelines

Population Exposures are Significant overnment has Taken Action


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How Much Fish is Safe?

Do Not feed children swordfish,shark, mackerel (King), and tilefish.

Chunk light vs solid white

albacore (limit amt based on weight)

Serve a variety of fish and seafood -

Haddock, pollock and shrimp areamong the low fat, low mercury

choices.

Enter your body

weight in pounds:

Select the species of

fish you eat:

et your Results!

IATP Fish Calculator

www.iatp.org


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Benefits of Maternal Fish Consumption

Lessened by Mercury Exposure

Fish is a good food source:

Source of protein, iron, vitamin E, selenium, andlong chain n-3 polyunsaturated fatty acids

Higher fish consumption associated withimprovedinfant cognition

However...Higher mercury (even very low dose)associated with reducedcognition

Suggests eating fish with less mercury

Oken E et al., EHP 2005


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Case 5 -

Occupational/Take Home Exposures

A day laborer goes to the ER for a work related injury.

He is working on demolishing a firing range so a lead

level is obtained and is 74 mcg/dl after 3 days on this job.

Four other workers tested between 57 and 98

(all worked less than 2 weeks). What should be done? None had previously worked with

lead.

Hipkins KL, Materna BL, Payne SF, Kirsch LC.,Clin Pediatri 2004


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Case 5 - continued

Occupational/Take Home Exposures

9 children of three workers tested between 13 and34 mcg/dl. (highest 18 month old)

Wife of one with symptoms and Pb level of 36

mcg/dl.

Workers may bring home hazards on clothing,shoes, and body.

In 2001-2002 year, 22% of California childhood leadpoisoning cases had potential contribution fromoccupational sources.


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KEY

CONCEPTS


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Case 6

Exposure but no Symptoms

Father concerned that for past seven months oily

residue found on driveway/car

Children play in that area

Finally determined coming from power transformer

just off property

Is there potential danger?

Power company contacted and said nothing to

worry about

Know Your Resources:

ATSDR, EPA regional office, PEHSU, state offices, AOEC


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PCB Exposure In Utero

Health Effects:

Decrease in full scale and verbal IQ

at 11 years old

Decrease in word and reading comprehension

Decrease in memory and attention


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Breastfeeding is Best for Baby


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Second Hand Smoke (SHS)


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Developmental Effects

Fetal rowth: LBW and decreased birthweightSudden Infant Death Syndrome

Respiratory EffectsAcute lower RTIs in childrenAsthma induction and exacerbation-children/adults

Chronic respiratory symptoms in childrenEye and nasal irritation in adultsMiddle ear infections in children

Carcinogenic EffectsLung Cancer, Nasal Sinus CancerBreast Cancer

Cardiovascular EffectsHeart disease mortality and morbidity

Effects Causally Associated w/ SHS Exposure

CAL EPA 2005


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SHS & Breast Cancer - PremenopausalWomen

14 Studies Reviewed -

13 found an Increase in

Risk (7 statistically significant)

70% Increase in Breast

Cancer Risk

Windows of susceptibility

during rapid proliferation

CAL EPA 2005


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Smoking Hazards

Addressed at Various Life Stages


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Summary

The body of scientific evidence continues to build

regarding the impact of environmental toxicants on

childrens health

A precautionary approach that emphasizes

prevention is good patient and public health

uidance on preventing exposures to children and

families can be incorporated by pediatric providers

into well child visits using the Pediatric

Environmental Health Toolkit

Society needs to work on upstream prevention

issues beyond the clinical setting


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Acknowledgements

Primary Author:

Mark Miller MD MPH

Contributing Authors/Reviewers:

Michelle ottlieb MEM, uenter Hofstadler MD,Brian Linde MD, Siobhan McNally MD,

Marybeth Palmigiano MPH, Kathy Shea MD,

ina Solomon MD MPH, Maria Valenti,

David Wallinga MD MPA


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Planning and Development Physician roup

California

Lisa Asta MD FAAP - Chair, Department of Pediatrics, John Muir MedicalCenter

uenter Hofstadler MD MPH FAAP - Pediatrician, Contra Costa Regional

Medical Center

Brian Linde MD FAAP - Pediatric Hospital Based Specialist, Kaiser

Permanente, Oakland, California

Mark Miller MD MPH FAAP - Pediatrician and Director, UCSF Pediatric

Environmental Health Specialty Unit

Massachusetts

Siobhan McNally MD FAAP - Berkshire Medical Center and the University of

Massachusetts Medical School

Minnesota

David Wallinga MD MPA - Senior Scientist and Antibiotic Resistance Project

Director, Institute for Agriculture and Trade Policy


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Greater Boston and San Francisco Bay Area Physicians for SocialResponsibility UCSF Pediatric Environmental Health Specialty Unit

For More Information

reater Boston Physicians

for Social Responsibility

617- 497-7440 - www.igc.org/psr

training program for health care providers regarding toxic chemicals and children

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